A systematic evaluation of paediatric allergy pathways in the West Midlands

This thesis considers the design of paediatric allergy services in the West Midlands (WM) region. It is presented in 3 parts: the first discusses a systematic review of allergy service delivery pathways across the UK and the rest of the world; The second quantifies the burden of paediatric allergy across the WM and compares it with the rest of the country using data from the health information network (THIN) database for primary care and the hospital episodes statistics (HES) database for secondary care. The final part ascertains the experiences of parents in the WM region who have accessed these services through a qualitative study and elicits parental preferences for these services using a discrete choice experiment. The main argument put forth in this thesis is that services in a financially constrained environment should be planned efficiently and be responsive to the needs and preferences of the local population. A systematic way method to achieve this is presented along with recommendations for improving the efficacy and efficiency of paediatric allergy pathways in the WM region

Congruence of the current practices in Hymenoptera venom allergic patients in Poland with EAACI guidelines

Introduction: Venom immunotherapy (VIT) practice is the definitive treatment for patients with potentially fatal allergic reactions to Hymenoptera stings. The aim is assesing compliance of VIT practice in Poland with the current European Academy of Allergy and Clinical Immunology (EAACI) guidance. Material and methods: A multicentre study was carried out using a structured questionnaire which was sent by post to all VIT practitioners in Poland. Some questionnaire items were altered, in comparison to original version by adding additional answer options or alowing multiple answer option. The response rate was 100%. The obtained results were compared with the published EAACI guidelines. Results: Twenty-six Polish centres took part in the survey. SSIgE and skin prick tests (SPT) are together used as the first line of investigation, whereas confirmatory intradermal tests (IDT) are applied in half of centres. Only a few centres measure baseline serum tryptase levels. The ultra-rush protocol is preferred. Antihistamine pre-medication is routinely practiced. A target dose equal to 100 µg is used in most centres. A 6-week interval between booster doses is the most frequent. Five years is considered as an optimal VIT duration. Before the VIT completion, SSIgE is evaluated in fifty percent of centres, whereas sting challenge is considered by half of responders. Conclusions: There are some differences between current practice in Poland and the EAACI recommendations, indicating areas requiring better compliance. Comparision between Poland and the United Kingdom revealed that health service organization and health care funding may play a major role in the provision of allergy services. This may affect the extent to which international guidance may be applied in individual countries. It is worth considering conducting the same survey in other European countrie

Effect of HIV-1 infection on T-Cell-based and skin test detection of tuberculosis infection

RATIONALE: Two forms of the IFN-gamma release assay (IFNGRA) to detect tuberculosis infection are available, but neither has been evaluated in comparable HIV-infected and uninfected persons in a high tuberculosis incidence environment. OBJECTIVE: To compare the ability of the T-SPOT.TB (Oxford Immunotec, Abingdon, UK), QuantiFERON-TB Gold (Cellestis, Melbourne, Australia), and Mantoux tests to identify latent tuberculosis in HIV-infected and uninfected persons. METHODS: A cross-sectional study of 160 healthy adults without active tuberculosis attending a voluntary counseling and testing center for HIV infection in Khayelitsha, a deprived urban South African community with an HIV antenatal seroprevalence of 33% and a tuberculosis incidence of 1,612 per 100,000. MEASUREMENTS AND MAIN RESULTS: One hundred and sixty (74 HIV(+) and 86 HIV(-)) persons were enrolled. A lower proportion of Mantoux results was positive in HIV-infected subjects compared with HIV-uninfected subjects (p < 0.01). By contrast, the proportion of positive IFNGRAs was not significantly different in HIV-infected persons for the T-SPOT.TB test (52 vs. 59%; p = 0.41) or the QuantiFERON-TB Gold test (43 and 46%; p = 0.89). Fair agreement between the Mantoux test (5- and 10-mm cutoffs) and the IFNGRA was seen in HIV-infected people (kappa = 0.52-0.6). By contrast, poor agreement between the Mantoux and QuantiFERON-TB Gold tests was observed in the HIV-uninfected group (kappa = 0.07-0.30, depending on the Mantoux cutoff). The pattern was similar for T-SPOT.TB (kappa = 0.18-0.24). Interpretation: IFNGRA sensitivity appears relatively unimpaired by moderately advanced HIV infection. However, agreement between the tests and with the Mantoux test varied from poor to fair. This highlights the need for prospective studies to determine which test may predict the subsequent risk of tuberculosis

Atraumatic splenic rupture due to covid-19 infection

Background: Covid-19 is a novel disease caused by the severe acute respiratory coronavirus (SARS-CoV2). We discuss a gentleman who presented with an atraumatic rupture of the spleen secondary to this infection. Brief summary of presentation: A 57-year-old service engineer was brought into the emergency department after having collapsed at home. RT-PCR was positive for covid-19 infection. CT scan showed evidence of haemoperitoneum and splenic rupture. He underwent splenic artery embolisation and required ventilatory and circulatory support on ITU. He made a full recovery and was discharged home 3 weeks later. Discussion and relevance: Atraumatic splenic rupture is a rare, potentially fatal condition which has been described as a complication of haematological and non-haematological malignancies, inflammatory disorders and infections. There is emerging evidence to suggest that covid-19 has a direct destructive impact on the spleen, causing lymphoid follicle attrition and nodular atrophy in addition to microvascular thrombosis and necrosis. This is the first report of atraumatic splenic rupture secondary to covid-19 infection, to our knowledge.</p

Hereditary Angioedema patient experiences of medication use and emergency care

Background: Hereditary angioedema (HAE) is a rare inherited illness characterised by recurrent swellings. Four percent of HAE attacks are life threatening throat swellings requiring urgent medical intervention. The aim of this study was to gain an in depth understanding of patient experiences of use of treatment and emergency care. Methods: 65 participants completed an online survey including open ended questions about their experiences and/or completed an in-depth interview. Interview participants were asked to share and talk about up to five images that they felt best represented their life experiences with HAE. Data were analysed using reflexive thematic analysis. Results: Treatment experiences highlighted the life changing nature of new treatments and benefits for quality of life, but also illustrated common barriers to treatment administration. Emergency care experiences illustrated how throat attacks and fear of their future occurrence could be traumatic. Discussion: Findings indicate that HAE patients need psychological support to process fears and negative experiences. In addition, psychological barriers to treatment administration must be addressed to ensure treatment is used effectively. Education for emergency practitioners is also needed to improve emergency treatment and reduce the psychological burden of delayed emergency care.</p

Case Report Icatibant in the Treatment of Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema

We describe the case of a 75-year-old woman who presented with massive tongue and lip swelling secondary to angiotensinconverting enzyme inhibitor-induced angioedema. An awake fibre-optic intubation was performed because of impending airway obstruction. As there was no improvement in symptoms after 72 hours, the selective bradykinin B2 receptor antagonist icatibant (Firazyr) was administered and the patient&apos;s trachea was successfully extubated 36 hours later. To our knowledge this is the first documented case of icatibant being used for the treatment of angiotensin-converting enzyme inhibitor-induced angioedema in the United Kingdom and represents a novel therapeutic option in its management

Cycle threshold values are inversely associated with poorer outcomes in hospitalised patients with Covid-19:a prospective, observational cohort study conducted at a UK tertiary hospital

ABSTRACT: This single-centre observational study demonstrated that lower cycle threshold (Ct) values (indicating higher viral loads) on admission to hospital were associated with poorer outcomes in unvaccinated, hospitalized patients with coronavirus disease 2019 (COVID-19). Demographic and outcome data were collected prospectively for all adult patients who tested positive for severe acute respiratory syndrome coronavirus-2 on admission to the University Hospitals North Midlands NHS Trust between 1 February and 1 July 2020. Nasopharyngeal swab samples were obtained, and a valid Ct value was determined for all patients using the Viasure reverse transcription polymerase chain reaction assay, validated by Public Health England, on admission to hospital. Multi-variable logistic regression results based on data from 618 individuals demonstrated a significant inverse relationship between the odds of death and Ct values (adjusted odds ratio 0.95, 95% confidence interval 0.92–0.98, P=0.001). The association remained highly significant after adjusting for known clinical risk factors for COVID-1

Cycle threshold values are inversely associated with poorer outcomes in hospitalized patients with COVID-19:a prospective, observational cohort study conducted at a UK tertiary hospital

This single-centre observational study demonstrated that lower cycle threshold (Ct) values (indicating higher viral loads) on admission to hospital were associated with poorer outcomes in unvaccinated, hospitalized patients with coronavirus disease 2019 (COVID-19). Demographic and outcome data were collected prospectively for all adult patients who tested positive for severe acute respiratory syndrome coronavirus-2 on admission to the University Hospitals North Midlands NHS Trust between 1 February and 1 July 2020. Nasopharyngeal swab samples were obtained, and a valid Ct value was determined for all patients using the Viasure reverse transcription polymerase chain reaction assay, validated by Public Health England, on admission to hospital. Multi-variable logistic regression results based on data from 618 individuals demonstrated a significant inverse relationship between the odds of death and Ct values (adjusted odds ratio 0.95, 95% confidence interval 0.92–0.98, P=0.001).</p

Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study.

OBJECTIVE: To compare the effectiveness and acceptability of outpatient polypectomy with inpatient polypectomy. DESIGN: Pragmatic multicentre randomised controlled non-inferiority study. SETTING: Outpatient hysteroscopy clinics in 31 UK National Health Service hospitals. PARTICIPANTS: 507 women who attended as outpatients for diagnostic hysteroscopy because of abnormal uterine bleeding and were found to have uterine polyps. INTERVENTIONS: Participants were randomly assigned to either outpatient uterine polypectomy under local anaesthetic or inpatient uterine polypectomy under general anaesthesia. Data were collected on women's self reported bleeding symptoms at baseline and at 6, 12, and 24 months. Data were also collected on pain and acceptability of the procedure at the time of polypectomy. MAIN OUTCOME MEASURES: The primary outcome was successful treatment, determined by the women's assessment of bleeding at six months, with a prespecified non-inferiority margin of 25%. Secondary outcomes included generic (EQ-5D) and disease specific (menorrhagia multi-attribute scale) quality of life, and feasibility and acceptability of the procedure. RESULTS: 73% (166/228) of women in the outpatient group and 80% (168/211) in the inpatient group reported successful treatment at six months (intention to treat relative risk 0.91, 95% confidence interval 0.82 to 1.02; per protocol relative risk 0.92, 0.82 to 1.02). Failure to remove polyps was higher (19% v 7%; relative risk 2.5, 1.5 to 4.1) and acceptability of the procedure was lower (83% v 92%; 0.90, 0.84 to 0.97) in the outpatient group Quality of life did not differ significantly between the groups. Four uterine perforations, one of which necessitated bowel resection, all occurred in the inpatient group. CONCLUSIONS: Outpatient polypectomy was non-inferior to inpatient polypectomy. Failure to remove a uterine polyp was, however, more likely with outpatient polypectomy and acceptability of the procedure was slightly lower

Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study.

OBJECTIVE: To compare the effectiveness and acceptability of outpatient polypectomy with inpatient polypectomy. DESIGN: Pragmatic multicentre randomised controlled non-inferiority study. SETTING: Outpatient hysteroscopy clinics in 31 UK National Health Service hospitals. PARTICIPANTS: 507 women who attended as outpatients for diagnostic hysteroscopy because of abnormal uterine bleeding and were found to have uterine polyps. INTERVENTIONS: Participants were randomly assigned to either outpatient uterine polypectomy under local anaesthetic or inpatient uterine polypectomy under general anaesthesia. Data were collected on women's self reported bleeding symptoms at baseline and at 6, 12, and 24 months. Data were also collected on pain and acceptability of the procedure at the time of polypectomy. MAIN OUTCOME MEASURES: The primary outcome was successful treatment, determined by the women's assessment of bleeding at six months, with a prespecified non-inferiority margin of 25%. Secondary outcomes included generic (EQ-5D) and disease specific (menorrhagia multi-attribute scale) quality of life, and feasibility and acceptability of the procedure. RESULTS: 73% (166/228) of women in the outpatient group and 80% (168/211) in the inpatient group reported successful treatment at six months (intention to treat relative risk 0.91, 95% confidence interval 0.82 to 1.02; per protocol relative risk 0.92, 0.82 to 1.02). Failure to remove polyps was higher (19% v 7%; relative risk 2.5, 1.5 to 4.1) and acceptability of the procedure was lower (83% v 92%; 0.90, 0.84 to 0.97) in the outpatient group Quality of life did not differ significantly between the groups. Four uterine perforations, one of which necessitated bowel resection, all occurred in the inpatient group. CONCLUSIONS: Outpatient polypectomy was non-inferior to inpatient polypectomy. Failure to remove a uterine polyp was, however, more likely with outpatient polypectomy and acceptability of the procedure was slightly lower